Lees Health

Naturopathic Medicine Intake Form

Todays Date: ____________

Last Name: _______________________ First Name: ________________________ Address: _______________________________________ City: __________________State: ______________ Post Code: __________ Sex: M/F ______ Email Address: __________________________ Cell Phone: ___________________Occupation: ________________________ Married Status: ___________________Emergency Contact: ________________ Relationship to Patient: __________Contacts Ph. Number: _____________ Referred by: _______________________

Please list any vitamins, minerals, herbal supplements, homeopathics, over the counter and prescribed medications and creams that you are taking.

Name: __________________________________ Date: ____________________

Supplement Manufacturers Form Dosage Frequency

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Describe any history of drug reaction/allergy:Other Comments: ______________________________________________________________________________________________________________________________________________________

Primary Health Concerns : Please list you concerns in order of Importance.

Concern Onset Frequency SeverityEx: Headache June 1992 4 times/ week Mild/mod/Sev

What types of therapies have you tried?

Diet Modification HerbsFasting HomeopathyHerbs ChiropracticVitamins and Minerals Conventional Drugs

What are your goals for this visit?

Please list any operations/surgical procedures/blood transfusions/major injuries (with dates):

Please List any Allergies: __________________________________________________Other allergies, sensitivities, or intolerances (eg. food, medication, environ-mental, chemical, etc.): _________________________________________________________________________________________________________________________________________________________________________________________________________________________________

What are the major stressors in your life? Do you consider severity of stress low, moderate or high? _________________________________________________________________________________________________________________________________________________________________________________________________________________________________

What are your interests/hobbies? ______________________________________________________________________________________________________________________________________________________I have indicated all of my known medical conditions above. I will alert the practitioner to any changes in my health status. It is my choice to receive naturopathic care.

Signature: _________________________________ Date: ___________________

MEDICAL HISTORY

Check all that apply to you. Please specify the date of diagnosis where applicable

Head Musculoskeletal CancerGlaucoma Carpal Tunnel

SyndromeType – Date Diagnosed

Dental Problems GoutOsteoporosis

Respiratory RheumatoidArthritis

Asthma Osteoarthritis Male Reproductive

Bronchitis EnlargedProstate

Emphysema Skin Prostate CancerPneumonia Easy Bruising Decreased Sex

DriveTuberculosis Eczema Infertility

Psoriasis Sex Transmitted Disease

Gastro Intestinal

Varicose Veins TypeDate Diagnosed

Colitis/Crohn’s Allergies/Hay Fever

Celiac DiseaseReflux Endocrine Date of Last

Prostate ExInflammatory Bowel Disorder

Chronic Fatigue

Hepatitis Diabetes Female Reproductive

GallbladderDisorders

Thyroid Disorder Menstrual Irregularities

Diverticulitis Obesity EndometriosisSeasonal Fibrocystic

Affective Disorder

Breasts

Insomnia Fibroids/ Ovarian Cysts

Cardiovascular Mental/EmotionalDepression

Female Reproductive

High Blood Pressure

Anxiety PCOS

Cholesterol Drug Addiction PMSHeart Disease Eating Disorder Menopause

SystemsArrhythmia Learning Breast CancerCirculatory Problems

Alcoholism Vaginal Infections

Clotting Disorders

ADD/ADHD Decreased Sex Drive

Heart Attack Urinary Tract Infection

Stroke Blood, Immune Infections

Sexually Transmitted Diseases

Nervous System

Autoimmune

Alzheimer Disease

Lyme Disease TypeDate Diagnosed

Epilepsy HIVParkinson’s AnemiaMultiple SclerosisRestless Legs

GenitourinaryKidney/Bladder Disease

List of Menstrual HistoryDate of last menstrual cycle

Are you pregnant. Y N

Length of cycle Age of 1st periodInterval of time between days.

List and PMS symptoms

Date of last GYN exam (eg) heavy/scanty flow,PAP - Date Clots, Form of Birth Control Cramping# of Children Breast tenderness# of Pregnancies Bloating# of Miscarriages Mood changes# of Abortions Other

Family History Family History(M) Mother (F) Father Heart Disease(B) Brother (S) Sister HIV(MP)Mother Parents High Blood Pressure(FP) Father Parents Kidney Disease © Children Liver Disease

AlcoholismNervous or Mental Disorder

Allergies Migraine - HeadFamily History Family HistoryCancer – Please Specify Type (s) Neurological Disorders

ObesityOsteoporosis

Crohn Disease Rheumatoid ArthritisDiabetes Thyroid DisorderDrug Abuse AlzheimerEpilepsy - Seizures OtherHearing Loss

Nutrition & Diet BeansLegumes

Mixed Food Diet DairyAnimal and Veg FishVegetarian Meat & PoultryVegan EggsOrganic FoodSalt Restriction Eating Habits

Fat RestrictionStarch/Carb Restriction

Skip MealsList which one(s) -

Calorie RestrictGraze small frequent meals

Please List any FoodRestrictions.

Generally eat on the run

(eg diary, gluten, soy Eat constantly whether hungry or not.Sleep

Food Frequency Hours per night# of times per day or week)Fruits Sleep Quality Poor -Vegetables Fair -Whole grains Good -

ExerciseType of Exercise

Total days of Eexercise Days of WeekDuration per w/outminutes Type of ExerciseType of Exercise Days of WeekDays of Week

Today’sType of ExerciseDays of Week Weight

Height

Lees Health

Informed Consent for Consultation and Treatment

I, _________________________________________, hereby authorize Lee-Anne at Lees Health, to perform the following specific procedures and services as necessary to facilitate in the treatment of myself or my minor child:

Medicinal use of Nutrition:

Therapeutic nutrition, nutritional supplementation.

Botanical Medicine: Botanical substances may be prescribed as teas, alcoholic tinctures, capsules, tablets or creams.

Homeopathic Medicine: The use of highly diluted quantities of naturally occurring plant, animal and mineral substances to generally stimulate the body’s healing responses.

Lifestyle and Nutritional Counselling and Hygiene

Diet therapy recommendations for exercise, sleep, stress and balancing of work and social activities, mind-body supportive counseling.

Flower Essence Flower Essences are used for calming and clearing. Using different flower essence in a Flower Essence Diagnosis can help to reduce certain stressful situations emotionally and physically.

Iridology and Scerology Iridology and Sclerology are the study of the iris and the sclera. By assessing the iris this gives information on the structure of your body and overall health. Where the assessment of the sclera gives how chronic your health is and also looks at your emotional health.

Live Blood Anaysis Live cell analysis, is the use of high-resolution dark field microscopy to observe live blood cells. Live blood analysis assesses the person’s blood and can assess the root cause and imbalance of their health.

I understand that Lee-Anne Stothard is a Naturopath at Lees Health and has an Advanced Diploma in Naturopathy and an Advanced Diploma in Herbal Medicine she has been a naturopath for14 years.

The naturopath will explain to me their assessment, the nature of their recommmendation, the expected prognosis and the anticipated costs, risks, benefits and experience of following various options. I understand that the focus of naturopathic care is to alleviate the underlying conditions that can bring about illness rather than the treatment of symptoms. I

understand that a record will be kept of the health use of naturopathic methods, I understand that the most effective results occur when I make long-term commitment to rebuild my health.

I voluntarily consent to the above procedures, realizing that the naturopath at Lees Health or any personnel have given no guarantees to me by regarding cure or improvement of my condition, I understand that I am free to withdraw my consent and to discontinue participation in these procedures at any time. I understand that it is not being recommended to me to discontinue any other treatment or care being provided by any other health care professional. I understand that this care will not replace the service of my primary care physician.

I understand that a record will be kept of the health services provided to me. This record will be kept confidential and will not be released to others unless so directed by myself or my representative or unless required by law. I understand that my medical record will be kept for a minimum of three, but no more that ten years after the date of my last visit. I understand that full disclosure of information has been made to me and all my questions have been answered to my full satisfaction.

I have read and understand the above statements.

Patient Name_____________________ Signature _______________________

Legal Guardian Name (if needed) _______________________

Signature ______________________

Date ________________

Lees Health

FEES & POLICIES

Appointments: Appointments are available Monday – Friday 9 am to 6 pm.Telephone appointments or Skype calls available.

Cancellation and Rescheduling of Appointments:

I request 24 hours prior notice for cancelling or rescheduling appointments for any visits (in-office or telephone or skype visits).

Schedule of Fees of Service:

Naturopathic Initial Visit – Adult (1 Hour) - $120.00Naturopathic Initial Visit – Child (1 Hour) - $100.00Naturopathic Follow Up (30 Min) - $ 80.00Iridology and Sclerology Consult (1 Hour) - $100.00Flower Essence Consult (1 Hour) - $100.00Live Blood Analysis Consult (1 Hour) - $100.00

Payment Policy:

Payment is due at the time of each visit. I have all options for payment - cash, visa/mastercard.